Burnout: a case for its formal inclusion in classification systems
Authors: Gordon Parker, Gabriela Tavella
Journal: World Psychiatry (2022)

Burnout is variably viewed as a social phenomenon, a psychological state, or a clinical condition. It currently lacks formal status as a mental disorder, not being listed in the DSM-5 and being simply positioned as an "occupational phenomenon" in the ICD-11, despite having a general population prevalence in the order of 30%, being debilitating, costing over US$ 300 billion/year to the global economy, and having status as an occupational "disease" in several European countries1. A recent review2 concluded that "it would be inappropriate, if not premature, to introduce burnout as a distinct mental disorder within any existing diagnostic classificatory system". In opposition, we offer a case for its formal listing by responding to the arguments put forward in that review and in other papers which may have prevented burnout from being accorded such recognition. The first argument has been that burnout is solely a Western cultural phenomenon – in effect, a culture-bound syndrome. On the contrary, there are reports of high burnout rates in Africa, South America and Asia1. Furthermore, even if burnout were indeed a culture-bound syndrome, this would not necessarily argue against its listing in classification systems, since psychiatry has long categorized many culture-bound syndromes (e.g., koro). A second point has been that burnout is a "new" phenomenon. On the contrary, while the term was coined in the mid-1970s, an early forerunner was "acedia" (listed in the 4th century AD as a cardinal sin), whose core symptoms were mental and physical exhaustion, torpor, non-productive activity, cognitive impairment, and a state of non-caring3, largely corresponding to the current conceptualization of burnout. A third consideration has been that burnout is commonly perceived as a "normative" condition. This may be true, but the same judgment would also hold for "stress", "anxiety" and other psychological conditions that are not always of clinical status, a reality generally addressed by adding a functional impairment component to their clinical definition. A fourth argument refers to the variegated conceptualizations present in the literature. Currently dominant is a triadic symptom model of burnout weighting emotional exhaustion, depersonalization/lack of empathy, and decreased personal accomplishment4. There are, however, several two-dimensional models and even measures weighting exhaustion as the only symptom5. If burnout simply corresponds to exhaustion, the term would be redundant, and its conceptualization could be validly challenged. Defining a syndrome with only one or two symptom criteria would also be problematic. However, more multi-faceted models and measures of burnout exist. The Burnout Assessment Tool (BAT)6 comprises four "core" and two "secondary" dimensions. The former are physical and mental exhaustion; mental distance (e.g., avoidance of contact with others, cynicism); emotional impairment; and cognitive impairment. The latter are psychological symptoms (e.g., insomnia, anxiety, worry) and psychosomatic complaints. We have recently proposed a new definitional model of burnout7 represented by a measure (the Sydney Burnout Measure, SBM)1 which captures domains of exhaustion, cognitive impairment, loss of empathy, withdrawal and insularity, and impaired work performance, as well as several anxiety, depression and irritability symptoms which are viewed as common burnout concomitants. The consistency across the BAT model, the SBM construct and descriptions of acedia argues for the validity of such a broader conceptualization of burnout and for a potentially meaningful set of operational criteria. Another issue is that of context specificity, with burnout long viewed as a work-related phenomenon and with "work" restricted to formal/paid employment. It has been argued2 that, if burnout's work-specific context were removed, two of the promulgated symptoms (i.e., depersonalization/cynicism at work, and reduced professional efficacy) would become irrelevant and reduce burnout's definition to exhaustion only. Clinically, however, we observe burnout in individuals not formally employed (e.g., parents looking after children with disabilities, or people caring for elderly relatives with high demands), while others have argued that "work" in the context of burnout should be viewed more broadly6. Thus, the context specificity concern is a straw man argument. A further key argument2 has been that burnout is actually depression (and thus is already classified). Whether burnout is or not synonymous with depression has long been debated8. A recent meta-analysis9 of 69 studies reported an overall correlation of r=0.52 between burnout and depression, concluding that the two conditions, although sharing some features, are "different and robust constructs". Indeed, although anxiety and depression correlate moderately to highly, this does not mean that they are synonymous, and diagnostic manuals have long listed separate categories of depressive and anxiety disorders. We argue for viewing the relationship between burnout and depression similarly. We now consider how burnout might be diagnosed as a mental disorder, respecting the need for a set of criteria/requirements in accord with DSM and ICD models. We suggest a criterion A requiring a work-based stressor, but allowing that it may occur in formal (i.e., paid) or informal (i.e., unpaid) "work" environments: "The individual has been exposed to excessive formal or informal work demands, that are generally in the form of excessive workload pressures but can also reflect physical environment, work inequity, role conflict or unfair treatment factors". A criterion B would list five symptoms (generated in empirical studies noted earlier): a) exhaustion (i.e., lack of energy across the day, lethargy, fatigue, waking up feeling tired); b) cognitive disturbance (i.e., concentration is foggy, attention less focused, material needs to be re-read); c) loss of feeling in work or outside of work (the individual feels disengaged, less empathic, and experiences a loss of joie de vivre); d) insularity (e.g., tendency to avoid others and to socialize less, deriving less pleasure from social interaction); e) compromised work performance (e.g., less driven to meet work responsibilities, contributing less at work, finding little things and chores frustrating, quality of work compromised in general and/or by making mistakes). To reduce the risk of over-diagnosis, we suggest that all five symptoms should be present. A criterion C would require (in line with the DSM and ICD) that the symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. A criterion D ("not caused by a medical condition or by the physiological effects of a drug or medication") is important to impose, as individuals may score high on burnout measures and meet the criterion B as a consequence of a range of other psychological conditions (e.g., depression), medical conditions (e.g., severe anaemia, post-COVID state), treatments (e.g., chemotherapy) or the effects of certain drugs. In conclusion, we believe that reasons for not listing burnout as a clinical condition can be countered, and offer candidate criteria for consideration, thus making a case for its formal inclusion in classification systems.